Journal of Indian Association of Public Health Dentistry

: 2019  |  Volume : 17  |  Issue : 3  |  Page : 247--252

Parental knowledge, attitude, and practice regarding the importance of primary dentition of their children in Kerala, India

Vennila Chandran1, R Balagopal Varma1, Teena Mary Joy2, Venkitachalam Ramanarayanan3, Bhat Sangeetha Govinda1, Medhini Madhava Menon1,  
1 Department of Pediatric Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
2 Department of Community Medicine, Amrita School of Medicine, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
3 Department of Public Health Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Correspondence Address:
Dr. Vennila Chandran
Department of Pediatric Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Ponekkara P.O., Kochi - 682 041, Kerala


Background: The primary dentition for children is, perhaps, the most essential and yet the most neglected concern by a parent. Often, these parents who are responsible for the health of the primary dentition of their children feel that primary teeth eventually shed, and hence does not deserve heed on providing adequate oral health. Aim: The aim of this study was to evaluate the parental knowledge, attitude, and practices on the importance of primary dentition of their children. Materials and Methods: An institution-based cross-sectional study was done among parents of children below 12 years of age. A 25-item semi-structured questionnaire, in both English and Malayalam languages, was prepared for the data collection. Statistical analysis was done using the Statistical Package for the Social Sciences. The quantitative variables were described as mean and standard deviation. To find out the association between categorical variables, the Chi-square test was applied. A multivariate logistic regression was done to find the independent predictors of knowledge. P <0.05 was considered statistically significant. Results: A total of 473 parents participated in the study. About 55.4% of the parents were found to have poor knowledge, while 58.4% and 55.2% of the parents were found to have good attitude and practice about the importance of primary dentition, respectively. There was a significant relationship between knowledge ( P = 0.0001), attitude ( P = 0.001), and practices ( P = 0.017) of the parents with their level of education. Furthermore, a significant association was found between the knowledge of parent and the area of residence ( P = 0.036) and attitude of the parent with that of the gender of the child ( P = 0.043). Conclusions: Majority agreed that primary teeth were important along with the knowledge that dental diseases were related to health problems. Education played a major role in parental awareness of primary dentition.

How to cite this article:
Chandran V, Varma R B, Joy TM, Ramanarayanan V, Govinda BS, Menon MM. Parental knowledge, attitude, and practice regarding the importance of primary dentition of their children in Kerala, India.J Indian Assoc Public Health Dent 2019;17:247-252

How to cite this URL:
Chandran V, Varma R B, Joy TM, Ramanarayanan V, Govinda BS, Menon MM. Parental knowledge, attitude, and practice regarding the importance of primary dentition of their children in Kerala, India. J Indian Assoc Public Health Dent [serial online] 2019 [cited 2021 Oct 27 ];17:247-252
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Full Text


According to the American Academy of Pediatric Dentistry (AAPD), the guidance of eruption and development of the primary, mixed, and permanent dentitions are an integral component of comprehensive oral health care for all pediatric dental patients.[1] Riedy et al. stated that system-level factors such as societal, environmental, and cultural are important determinants of oral health and concluded that maternal factors such as health beliefs, attitudes, and knowledge about oral health behavior are responsible for high caries incidence across the five ethnic groups in their study.[2] The eruption of primary teeth begins at 6 months and is completed by around 3 years of age. A complete set of primary dentition is an essential prerequisite in learning correct pronunciation, developing mastication, guiding the permanent dentition to a proper occlusion, and good esthetics. Although permanent teeth are already partly formed in children aged 0–3 years, an eruption occurs from about 6 years on. As the first molar erupts, the oral cavity constitutes of mixed dentition, thus heightening the risk of caries. Therefore, it is imperative that the primary dentition is maintained in good health and preserved until normal exfoliation.

The foundation for healthy permanent teeth in children and teenagers is laid during the 1st year of life. Several studies have shown that improper frequency of diet, unhealthy eating habits, and inadequate oral hygiene measures during the first 3 years of life are related to tooth decay in children.[3],[4],[5] A disregarded carious primary teeth further increases the risk of developing caries in permanent teeth and thus affecting the quality of life.

The role of parents is a critical one, as they are the primary caregivers during the early formative stages of their children. A child is cognizant and alert to social stimuli such as praise, compliments, and affection, and they learn best by imitating their parents. Parents as consistent role models are the key to establish a healthy oral practice in children and making them understand the importance of oral hygiene.

Various studies on the epidemiology of dental caries in children in Kerala show a high prevalence rate of 49%–54%[3],[4],[5] and suggested an increasing need of awareness among the parents. Although Kerala has a literacy rate of more than 93%,[6] high treatment needs indicates poor awareness regarding oral health and caries prevention. Without the basic knowledge of caries risk factors, the importance of primary dentition and its functions, and appropriate oral hygiene practices, parents cannot be the best decision-makers with regard to good oral health of a child. Hence, the aim of this study was to assess parent's knowledge, attitude, and practice (KAP) of the primary dentition and its importance.

 Materials and Methods

An institution-based cross-sectional study was conducted among parents of children aged below 12 years, who attended the department of pediatrics, of our sister medical institute for their children's ailments during the months of March–October 2017. A semi-structured, self-administered questionnaire was used to obtain the required data. The parents were requested to complete a 25-item questionnaire comprising of preselected questions adopted from previously validated questionnaires, related to parental knowledge and awareness about the oral health of children.[7],[8],[9],[10],[11] The questionnaires were pretested for face validity among 12 parents of children below 12 years of age and these parents were excluded from the main study. Voluntary informed consent was obtained from the parents before the commencement of the study.

The first part of the questionnaire consisted of the demographic details of the participant such as name, age, gender, educational qualification, child's age, gender, number of siblings to the child accompanied by the parent, and place of residence.

The second part had questions related to the knowledge about the primary dentition, functions, tooth shedding, effects on permanent teeth, and importance of fluoride. The third part consisted of questions related to the attitude of the parents toward the treatment of infected primary tooth and their willingness to comply with the treatment options for such teeth. Their beliefs associated with the extraction of primary tooth were also recorded. The fourth part consisted of the practices adopted for routine oral hygiene and measures undertaken for managing an infected tooth.

A score of 1 was recorded for all the answers of knowledge that were correct, while 0 for those incorrect. The attitude questions were designed, carrying both negative and positive statements. The responses were rated and were assessed from the following options: (1) agree, (2) disagree, and (3) uncertain.[7] The statements in a question that have already been proven true, but has an unfavorable response given by the participants, a score of 0 is marked in the agree/disagree category.

The sample size was calculated based on the mean value of knowledge scores observed in a study by Jain et al.[7] (knowledge: 3.25 ± 2.1). With a 95% confidence interval and 10% allowable error, the minimum sample size was 160. The formula used for calculation was: n = Z 1−α/2 σ2/Σ2 μ2.

1−α/2 = 1.96 for 95% confidence interval.

μ =3.25.

Σ =10%.

σ =2.1.

Ethical approval to conduct the study was obtained from the institutional review board (IEC-AIMS-2017-DENT-093 dated March 6, 2017). The questionnaires, both in English and the local languages (Malayalam), were personally distributed to parents by the principal investigator. The participants received a full explanation regarding scoring their response. Assistance was offered for those who desired help in understanding the questions. The questionnaires were duly collected from the participants on the same day after 15–20 min. The study was planned and carried out for a period of 3 months, resulting in a sample of 473.

The collected data were coded, tabulated, and analyzed using IBM SPSS Statistics for Windows, Version 20.0. (Armonk, NY: IBM Corp.). The quantitative variables were described as mean and standard deviation. To find out the association between categorical variables, the Chi-square test was applied. A multivariate logistic regression was done to find the independent predictors of knowledge about the importance of primary dentition. P < 0.05 was considered statistically significant.


Of 473 parents who participated in the study, 33.6% were fathers and 66.4% were mothers. Around 27 questionnaires, which were incomplete or showed recording of more than one response, were excluded. Majority of the participants had male child (53.9%). The mean age of parents in years was found to be 35.16 ± 6.07, and the mean age of children in days was 2277.56 ± 1217.06. The scoring for the education level of the parents was adopted from the Modified Kuppuswamy's Socioeconomic Status Scale, revised for 2016[12] [Table 1].{Table 1}

The percentage of correct response to the KAP about the importance of primary dentition was 44.6%, 58.4%, and 55.2% respectively. Around 55.4% of the parents were found to have poor knowledge, while 41.6% and 48.8% of the parents were found to have poor attitude and practice about the importance of primary dentition, respectively [Table 2].{Table 2}

There was a significant association between knowledge of the parent and their area of residence ( P = 0.036) [Table 3]. The multivariate logistic regression analysis for independent predictors for knowledge shows a significant association with the education level of the parents ( P = 0.001) with an odds ratio of 2.12 [Table 4]. There was a significant relationship between the KAPs of the parents with that of their educational level ( P = 0.017) [Table 3], [Table 5] and [Table 6] and the attitude of the parents with that of the gender of the child, respectively ( P = 0.043) [Table 5].{Table 3}{Table 4}{Table 5}{Table 6}

The scoring system to assess the response for the practice questions was formulated as 4 for the best practice, and 3, 2, and 1 (fair/average) were categorized under poor practice. Of the parents, 41% of the respondents had the practice of changing the child's tooth brush every 6 months, 27.3% once in a month, 19.9% when the bristles fray out, and 11.8% were not particular. It was noted that 63% of the parents visited a dentist while having oral problems, whereas 6.1% of them had the good practice of visiting the dentist at least once in a year. In a situation when a primary tooth requires an extensive treatment with multiple appointments with the dentist, 85.6% of the parents agreed that they would opt for the treatment and 14.4% of the parents would deny the treatment due to the factors such as time constraint (2.9%), expenditure (58.8%), and both time and money (35.3%) [Table 6].


This study examined the knowledge, attitude, and oral health practices of the parents and its association with various factors that influence the importance of primary dentition of their children. As per the population census of India 2011, Kerala has the highest literacy rate in India, with a wide gender disparity in literacy rate of 96% for men and only 92% for women.[6] The AAPD states that low education level of mothers[13] is one among the multilevel influences for the high prevalence of dental caries among the children. Retnakumari and Cyriac[3] and Kuriakose et al.[4] reported an association between caries incidence and education status of parents. This result corroborated with findings of the present study, which showed the mother's qualification with high school and above was significantly associated with KAP about the importance of primary dentition. Similar results have been found in the studies done by Jain et al.,[7] Thakare et al.,[9] Chen et al.,[14] and Suresh et al.,[15] among the immigrant Taiwanese population.

The AAPD recommends that optimal fluoride is essential for all dentate infants and children after assessing the child's total fluoride exposure.[13] The response of the parents regarding the role of fluoride preventing tooth decay (62.4%) was quite encouraging. This result coincides with the following studies which derived standard inference pertaining to the importance of parental involvement in their child's oral health care. Gussy et al.[16] from their study among the families residing in the rural Victoria found that appropriate use of fluoride toothpaste requires good parental understanding. A study among the sub-urban Nigerian families by Folayan et al.[17] reported that the odds of the child using fluoridated toothpaste increased by over 39 folds, when the mother uses fluoridated toothpaste. Adair et al.[18] stated that “children are more likely to be caries-free if their teeth are brushed twice daily using fluoride toothpaste, with parental involvement.” Several studies[7],[8],[11],[19] have witnessed poor knowledge regarding the role of fluorides, whereas Thakare et al.[9] reported a positive awareness about fluorides among the parents.

A laudable percentage of parents (97.5%) agreed that children should be guided and supervised by parents while brushing. A study done by Naidu and Davis states that supervision of brushing was seen as important due to an understanding that the child lacked manual dexterity and brushing on their own would be somewhat ineffective, as described among the Trinidadian population.[20] The similar justification might be the possible reason among this study population. In contrary, to the rural Victorian population, half of the participants felt that children were capable of brushing their own teeth by the age of 4 years.[16] Wong et al. found that the parents felt that a child of below 5 years was expected to start brushing on his or her own.[21]

Although the study population had a good knowledge that sweets, chocolates, and bakery items can lead to tooth decay, ambiguity was observed regarding the time of intake of sugars. This result was in concurrence with the study done by Jain et al.,[7] which throws light on the restricted knowledge among the respondents regarding the frequency of snacking and tooth decay.

In our study, very few parents (below 15%) viewed dental treatment for primary teeth as unimportant and the most common reason for unwillingness was deemed to be a waste of time and money on temporary dentition. A similar reason was observed by Mounissamy et al.[8] among the study population (79.2%) in Chennai, for not treating the primary teeth, which was also in line with the studies done by Jain et al.[7] and Suresh et al.[15]

Thakare et al.[9] observed in their study that the majority of the parents were aware of the importance of primary teeth. Similarly, participants in our study felt that the primary dentition were important and also wanted to preserve until their exfoliation. This indicated that the parents followed a good oral health practices for their children. On contrary, Wong et al.[21] observed the cultural belief among the Chinese parents that the primary teeth were not considered as important as the adult teeth. Parents who held a strong belief to this declined dental treatment for their children, and those parents who recognized its importance chose to bring their children for dental treatment.

Shivaprakash et al. found that there was no significant difference ( P > 0.05) between the rural and urban parents' awareness on infant oral health.[19] In our study, majority of the participants belong to rural areas, who lacked knowledge on the importance of oral health in children. The plausible elucidation for such high percentage of poor knowledge could be due to the paucity of oral health-related information for young children among the parents and the recommendations on how to competently translate those information into daily routines. Another fact as stated by Glick et al. was the unequal geographic distribution of practicing dentist which resulted in an oversupply in some urban areas, with a critical shortage in the world's poorer and remote areas.[22]

Although statistically not significant, mothers were found to have a better knowledge about the functions and importance of the primary dentition. It was customary that the mothers accompanied their children to seek medical advices, which was evident from our study. Hence, they shared a primary role in making decisions for their children, which might influence them to acquire more knowledge about their health-care needs.

In this study, parents having female children showed a better attitude towards care for primary dentition than those of male children. This could probably be due to the fact that parents were more concerned about the dental esthetics for the girl child. This result substantiated the finding in a study by Kuriakose et al.[4] that boys were affected with caries more than girls.


KAP regarding the importance of child's primary dentition was good only in about half the study population (parents). Good practices for maintaining child's oral health was less than satisfactory in some aspects. Education had a major role to play in their care of child's teeth. Hence, improving awareness among parents/caregivers is crucial in the care of child's oral health.


The authors would like to acknowledge the contributions of Mrs. Nimitha Paul (Biostatistician, Dept. of Community Medicine, Amrita School of Medicine) for her valuable inputs in the study.

Financial support and sponsorship

This study was self-funded.

Conflicts of interest

There are no conflicts of interest.


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